What’s Behind My Low Sex Drive? Female Sexual Dysfunction and Decreased libido Causes, Diagnosis, and Treatment

Are you noticing less interest in sex or in sexual satisfaction? If so, know that you are not alone. Four out of ten women experience  sexual dysfunction at some time in their lives. For half of these women, it’s a cause of great emotional distress. The chance of experiencing sexual dysfunction changes over a woman’s lifetime. And it peaks between ages 45-65. But if female sexual dysfunction is so common, why aren’t more people talking about it? Studies show that most women are hesitant to bring up sexual dysfunction with their doctor. Oftentimes, women don’t bring it up unless their doctor asks. But, doctors are also often hesitant to ask patients about their sexual health. Here are some reasons why.  

Reasons Doctors Don’t Discuss Sexual Function  

1. Feel uneasy asking about sexual problems.
2. Fear the patient may feel uneasy talking about this problem.
3. Have little experience treating sexual problems.
4. Have a busy schedule. And this type of discussion takes time.
5. Underestimate how common sexual problems are. Doctors recognize sexual concerns in less than half of their patients. 

Despite the reason behind the reluctance, discussion of your sexual health is important. Here are some ways in which you may broach this topic with your provider.  

 How to Discuss Sexual Function With Your Doctor 

1. “I am having some concerns about my sex life.” 
2. “I do not enjoy sex like I used to.” 
3. “Lately, I have been having trouble with physical intimacy. What can I do?” 
4. “I am just not interested in sex. Do you have any advice?” 
5. “I’m not satisfied with how often I have sex. What can I do? 

Our interest in sex and the ability to become aroused can vary throughout our lifetime. Hypoactive  Sexual Disorder  and  Arousal Disorders are the two most common forms of sexual disorders. Your desire for sex and your ability to become aroused is called your libido. Many things may affect your libido.

Reasons For Your Decreased Libido 

1. Emotional issues. For example, relationship problems, a history of sexual abuse, weight changes, stress, and negative attitudes toward sex impact your libido. 
2. Psychological issues like anxiety, depression, and poor body image.
3. Illness such as diabetes, high blood pressure, neurologic disease,  and premature ovarian failure. Biological Factors (fatigue, lack of sleep, pregnancy, breastfeeding, menopause).
4. Medications. To specify, drugs for depression, hormones, asthma, lung disease, high blood pressure, and insomnia all affect your sex drive.
5. Substance Abuse (alcohol, drugs).  

Model of Sexual Response

The Masters-Johnson model was one of the first sexual response models developed in the 1960s. In fact, it applied to both men and women. And its main focus was on the physical response of the genitals. In the 1970s, Helen Singer Kaplan, a psychologist and sex therapist, revised the Masters-Johnson model. Namely, Kaplan added how desire impacts your sexual response. According to these models, sexual response progresses as expected.

Masters- Johnson Sexual Response Model

1. Desire: Also called libido, refers to the urges, thoughts, and fantasies about sexual activity. (Kaplan’s model)
2. Interest/Excitement: the increase of sexual desire, during or in anticipation of sexual activity.
3. Arousal: A state of sexual readiness with mental (intense desire) and physical components (penile erection in men and vaginal lubrication in women).
4. Plateau: The sensation before reaching climax.
5. Orgasm: The physical and emotional peak of sexual satisfaction (ejaculation in men and rhythmic contractions of female genital muscles).
6. Resolution: A physical and mental state of relaxation after orgasm.

In general, this sequence of desire, interest, arousal, plateau, orgasm, and resolution is a pattern mainly followed by men. For women, sexual response is more complex. As a result, the making of alternative models of female sexual response began. For instance, in 2000, a circular model of sexual response gave equal value to emotional and physical satisfaction. Further, this revised model named both factors as vital outcomes of engaging in sexual activity. This model is called a circular model of female sexuality.

Circular Model of Female Sexuality

To be clear, your sexual function is not just about desire and emotional intimacy. Several additional factors impact intimacy. However, when comparing many studies published about women’s sexual function, there are a few common that affect a woman’s sexual function.

Reasons for Reduced Intimacy

• Vaginal dryness. Usually, this increases in menopause. And, it is a key factor in sexual function.
• A positive relationship between overall physical health and sexual function. If you have health concerns, you are less likely to think about sex.
• Lack of available partners. As we get older, the amount of available partners changes due to declining partnerships or the death or illness of a partner.
• Stress or mood symptoms. For example, depression and anxiety reduce sexual desire and function.

Another even more in-depth model of sexual response found that four factors relate and affect our sexual function. This is called the biopsychosocial (bio-psycho-social) model.

Biopsychosocial Sexual Response Model

1. Biological – refers to our hormonal, medical, and/or physical state.
2. Psychological- concerns how much stress, anxiety, and depression we may be feeling.
3. Interpersonal- considers our partner relationship.
4. Social/Cultural- shows how our attitudes about aging, sex, and religion affect our sexual intimacy.

Half of the women who had low sexual interest disorders reported a lack of emotional intimacy as the primary cause in one study. In fact, 85% of women had psychological factors. Depression was the most common. Likewise, 25% of the women had low testosterone levels (yes, women do produce low levels of testosterone).   

The issue of female sexual function is complex with varied causes. But, addressing depression, vaginal dryness, relationship strife, or any other organic concern should improve sexual function. When these medical issues are not the problem, you may have a diagnosis of Female Sexual Interest or Arousal Disorder. Collectively, these disorders are called decreased libido. If decreased libido or arousal is the reason, then the approach for the treatment is different.  

Criteria for medical diagnosis of female sexual interest/arousal disorder: 

1. At least three symptoms of decreased libido. 
2. Symptoms that persist for at least six months 
3. Emotional distress caused by symptoms.

Symptoms of Decreased Libido: 

There are many symptoms of decreased libido. For instance, patients usually have an absence or decrease in: 

•  Interest in sexual activity. 
•  Sexual thoughts or fantasies.
•  Initiation of sexual activity or responsiveness to a partner’s initiation. 
•  Excitement or pleasure during all or almost all sexual activity. 
•  Interest or arousal in response to sexual cues.
•  Genital or non-genital sensations during sexual activity in almost all or all sexual encounters. 

Having a decreased libido does not mean you no longer think about sex. You very well may. However, you may avoid rather than engage. So, the approach to a decreased libido may be to come up with a strategy to endure intercourse or simply get through it, so your partner may be satisfied.  

To determine the cause of your lowered sexual interest, your doctor may have you complete an evaluation using The Brief Index of Sexual Functioning for Women (BISF-W). This 22-item survey asks you to report on seven dimensions of sexuality. In most cases, this helps to determine your current level of sexual function and satisfaction.  

The Seven Dimensions of Sexual Functioning 

• Thoughts and desires. 
• Arousal.
• Frequency of sexual activity. 
• Receptivity/initiation.  
• Pleasure/orgasm.  
• Relationship satisfaction. 
• Problems affecting sexual function.  

After completing the survey, your doctor will perform a complete history and physical examination. They are looking for any evidence of physical or medical issues that may be adding to sexual dysfunction.   

A complete sexual history includes questions about: 

• Sexual and gender identity. 
• Onset, nature, and duration of symptoms. 
• Personal feelings about the symptoms. 
• Medications (prescription and over the counter). 
• Alcohol and drug use. 
• Partner’s health and sexual function.
• Relationship quality and communication. 
• Past or present physical/sexual abuse. 
• Physical activity. 
• Injuries. 
• Sleep quality. 
• Body image concerns.

The physical and gynecologic exam will focus on finding changes or abnormalities that may add to sexual dysfunction. Usually, blood-work is not needed at this time unless there is a specific concern. Once your evaluation is complete, there are a variety of treatment options depending on your initial diagnosis. 

Treatment Options for Decreased Libido

1. Outpatient Psychological Counseling or Therapy: 

This may include: 

• Sex-therapy. 
• Sexual skills training. 
• Couples-therapy.
• Marriage counseling. 
• Mindfulness-based therapy that focuses on stress reduction.  

Mindful therapy focuses on the present. It teaches us to live in the moment instead of worrying about the past or the future.   

2. Hormones: Estrogen and Testosterone

A decrease of estrogen by the ovaries creates many changes in a woman’s genitalia. To explain, a common change is the thinning of the vaginal lining. As a result, vaginal lubrication reduces and makes the vagina less tolerable to the friction of vaginal intercourse. This makes sex uncomfortable or even painful, hence the avoidance. 

Low-dose vaginal estrogen therapy is the preferred hormonal treatment for female sexual dysfunction due to menopausal changes in the genital area. 

Equally effective, there are vaginal tablets, gels, creams, and rings that contain estrogen. You and your doctor will decide if this is a good option for you. If so, you have many choices according to what you prefer. The body absorbs minimal amounts of estrogen when you use vaginal estrogen. Most of its effect is in the vagina. As the vaginal tissues become thicker, lubrication improves. And sex becomes more pleasant. 

However, did you realize that a woman’s body also produces testosterone? Even though that’s something we think of as a “male” hormone? Among other things, testosterone helps with our libido. As testosterone levels decline with age, it can affect our interest in sex. 

For postmenopausal women, short-term testosterone use for six months or less can improve sexual desire and arousal. But, testosterone use is not recommended for premenopausal women due to lack evidence showing benefits and the risks of potential harm. No medication should be used used in pregnancy for the treatment of decreased libido.

Postmenopausal women wearing a testosterone patch report a significant increase in satisfying sexual episodes, sexual activity, orgasms, and sexual desire. Unfortunately, we don’t know enough about testosterone’s safety and effectiveness for long-term use because most studies have not gone past six months. Additionally, the FDA has not approved testosterone for premenopausal women with interest or arousal disorder. The use of testosterone does carry the risk of experiencing potential side effects, some of which may be irreversible. In addition, the effects of long-term testosterone use (past six months) on heart disease and breast cancer risk are unknown and may be harmful.  

Potential Side Effects of Testosterone Therapy (not all-inclusive) 

• Unwanted hair growth (facial and body).  
• Acne.
• Possible voice deepening.  
• Enlargement of the  clitoris.  

3. Medications: Addyi, Viagra, and Wellbutrin

In 2015, a non-hormonal medication called Addyi was approved to treat sexual interest/arousal disorders in premenopausal women who have no history of depression. Addyi’s main side effects are dizziness, nausea, sleepiness, fatigue, and episodes of a dramatic drop in blood pressure and fainting. And the use of alcohol increases these side effects. Also, Addyi is expensive. In most cases, a one-month supply can cost as much as $830.

Despite all these potential side effects and costs, the expected benefit is minimal. Studies show minimal improvement in libido. Further, with the use of Addyi, you can expect to experience an increase of less than one more satisfying sexual episode per month. Additionally, users of the drug are required to sign a document stating that they will refrain from drinking alcohol while taking Addyi. 

Considering the very small improvement in libido, the cost, and the significant side effects, Addyi is not a practical solution for most women. Studies have also looked at the use of Viagra for the treatment of decreased libido in women. Results have been conflicting. And at this time, Viagra is not approved for use in women. 

Certain antidepressants may cause sexual interest and arousal disorder. However, the addition of the medication Wellbutrin can be beneficial. Women treated with Wellbutrin, in addition to their antidepressant, had more desire, arousal, lubrication, orgasm, and satisfaction than women who only took their antidepressant. 

4. Devices: 

In 2000, the FDA approved a battery-powered clitoral suction device called the Eros Clitoral Therapy Device to improve arousal and orgasm by increasing blood flow to the clitoris. But, there have been no well-controlled studies looking at the effectiveness of this device. Still, in 2017 a paper was published. It showed improvements in sexual function, satisfaction, sexually related distress, and genital sensation after using the device for three months. 

Summary: 

Healthy and satisfying sex life is a vital part of your overall well-being. Yet, normal versus abnormal sexual functioning in women remains mainly unknown. The definition of normal female sexual function continues to develop.  

Evolution of Knowledge of Female Sexual Disorder over Past 50 Years 

• Clearer definitions of female sexual disorders . 
• Models of female sexual response that reflect both the physical and emotional aspects of a women’s sexual experience.
• Emerging treatment options. 

The future of Decreased Libido. We need to: 

• Better understand women’s typical sexual activity and function during midlife and beyond. For instance, this should include how sex may or may not change with aging. 
• Determine why some women become distressed by changes in sexual function while others do not .  
• Continue to develop safe and effective treatments for female sexual dysfunction. Particularly, midlife and older women are often excluded from many studies.   
• Make behavioral therapy approaches more widely available as they have shown promise in the treatment of several types of female sexual dysfunction.  
• Using a biopsychosocial approach will allow researchers and healthcare providers to better understand and improve this key part of a woman’s well-being. To specify, this approach addresses the biology, psychology, cultural and interpersonal aspects of sexual health.

---

Written by: Lisa Shephard, MD Feb 23, 2020 | Editor: Dayna Smith MD | Reviewed Sep 08, 2020. Copyright myObMD Media, 2020

Glossary:

1. Sexual Dysfunction: Sexual dysfunction occurs when you have a problem that prevents you from wanting or enjoying sexual activity.
2. Libido: A person’s overall sexual drive or desire for sexual activity.
3. Gender Identity: A person’s sense of feeling female, male, or somewhere in-between. It may not go along with the sex they were assigned at birth.
4. Premature Ovarian Failure: Occurs when a woman’s ovaries stop producing hormones before they are supposed to.
5. Menopause: The time when a woman’s menstrual periods stops occurring for over one year and will not resume again.
6. Postmenopausal: The time in a woman’s life when she has gone through menopause and no longer menstruates.
7. Premenopausal: The time in a woman’s life before menopause occurs, when she is still having menstrual periods.
8. Labia: the fleshy folds that surround the opening of the vagina (the larger outer labia majora and smaller inner labia minora).
9. Clitoris: Corresponding to the penis in a male, the clitoris is highly sensitive when stimulated during sexual activity.
10. Urethra: the tube that leads from the bladder and transports urine outside the body. In females, the urethra is shorter than in the male, and it emerges above the vaginal opening.